Allergy History Form

Peninsula Paediatrics and Allergy - Allegy History

Required fields *

APPLICANT'S INFORMATION

Applicant's Name:

Applicant's Email Address

CHILD'S INFORMATION

Child's Name:

Date of Birth

Day

Month

Year

Does your child have/or ever had: (Please select – if yes from what age?)

Asthma

Age:

Hayfever

Age:

Eczema

Age:

Are there any foods or drinks to which your child has reacted to?

Yes No

If yes please list the food or drink, quantity eaten, age when it occurred, type of reaction and onset of reaction. (Example: Cows milk, 5ml at three months of age which caused a rash around mouth and vomiting within minutes; or Small (less than one teaspoon) of peanut butter with immediate itchy rash on face and swelling of lips).

*** If more than one food or drink is suspected, please upload a separate list***
(jpg, gif, pdf, doc, docx files accepted - max 10MB file size)

Please outline early milk feedings for your child and reasons (if any) for changes. (Example Breast fed for six months then S26 Gold, changed to soy formula at eight months because of vomiting and diarrhoea. Now on soy formula.)

At what age did your child start solids?

What solids can your child tolerate?

Are there any foods you avoid giving your child for any reason?

Are there any foods or drinks to which your child has reacted to?

Yes No

if YES, please name them

If YES, which family members (specify relationship to your child) and what allergy?

Please list below any allergy or asthma concerns you have with your child and what you would like addressed at your appointment. (For example: Asthma, Eczema, Food allergies or Hayfever). Please also list the treatments you are currently using (if any).

Concern 1

Concern 2

Concern 3

Concern 4

If allergies of any kind are a concern and an allergy test (skin prick test) is requested, you will need to discuss skin prick testing with your doctor and sign a consent form at your appointment.

PLEASE NOTE YOU MAY BE REQUIRED TO BRING SOME OF THE FOODS THAT YOU WANT TESTEDTO YOUR APPOINTMENT.

If your child will be undergoing skin prick testing please speak to our staff for information regarding food samples to bring to your appointment.

If your child has a skin condition, it is useful to bring photos of the rash and any swelling to aid in diagnosis.

Peninsula Paediatrics and Allergy - Allegy History

Infant, Toddler & Children allergy specialists

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